Radiation Oncology
Expert insights on radiation treatment planning, techniques, toxicity management, and multimodal cancer care.
Recent Discussions
In patients with skin squamous cell carcinoma invading the skull, what dose do you limit the brain when treating definitively with radiation?
Brain (excluding optic structures and brain stem) can handle all sorts of doses to limited volumes. I would just try to avoid dumping hotspots < 105-110% of your Rx dose into the brain and try to minimize the Rx dose, which will be dependent on anatomy and the extent of abutment/overlap of PTV with ...
How do you treat severe vaginal stenosis after radiation in a patient that is already compliant with dilators?
Local estrogen helps a lot. Compliance can be a problem. I suggest that the patient will cover their applicator with estrogen and insert after she goes to bed at night and just leave it in. It will usually come out during the night but this usually beats the patient having to take time out during th...
Do you routinely prescribe memantine for patients who will be receiving hippocampal sparing whole brain RT if they are already on donepezil, or is donepezil alone sufficient?
I typically prescribe memantine along with WBI and H/A. Not sure there ever was a study comparing the WBI component (with HA) with or without memantine. Maybe that study would show that the HA technique is the major benefit and the drug does very little. Lots of patients are on both memantine and Ar...
Should inoperable squamous cell carcinoma of the esophagus be treated to doses > 60 Gy?
The article mentioned does not, in my opinion, provide sufficient evidence to justify a change in clinical practice. As a general rule, I think we should be extremely careful about using data from retrospective data reviews, such as this review or the commonly used NCDB database, to assert that one ...
In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive vertebral body metastases, when do you prescribe lutetium-177 vs prophylactic spinal radiation?
Goals are different. Pluvicto is administered to improve pain, PFS, OS, and quality of life so it is SOC for patients who fail chemotherapy and have PSMA avid disease while good prophylactic RT is to prevent local bone-related events only.
For patients with large, partially or nearly obstructing rectal cancers, how do you sequence TNT in order to avoid complete obstruction and surgical diversion?
I personally favor starting with RT/chemo, but starting with chemo can work well. The more important issue is the side questions. First, there is a huge difference between a lesion that is large and one that is nearly completely obstructing. Unfortunately, many endoscopists use the term "obstructing...
Would you consider proton therapy as part of TNT for rectal cancer?
Show me the data. Our results with conventional 3D XRT are excellent with a low rate of chronic toxicities and even lower rates of pelvic recurrences.
Would you offer inguinal nodal RT to a patient with anal SCC (pT1N1a, + inguinal node) following APR in the setting of prior prostate + pelvic nodal radiation?
Inguinal lymph node dissection is not typically part of APR procedures. Even when surgical dissection of the inguinal lymph nodes is performed, the recurrence or failure rates in this region can still be significant, with some studies reporting failure rates of around 10-15% despite extensive surger...
How would you manage an aortocaval nodal recurrence of prostate cancer in a patient who previously received salvage radiation to the fossa and pelvic nodes?
One can do either with some rationale but more data on SBRT in this setting with the goal to either delay initiation of ADT (STOMP and ORIOLE) or maintain eugonadic status (EXTEND).These trials for OM did include patients with pa nodal recurrence.
What is your preferred fractionation scheme for spine SBRT for radioresistant histologies?
As long as it's safe, and I can meet the OAR constraints, I escalate the GTV (but not the entire VB) to 20-24 Gy in 1 fx, 28 Gy in 2 fxs, 30-33 Gy in 3 fxs, 35-40 Gy in 5 fxs. While more work has been published in escalation with single fraction, I find that it's easier to safely escalate those to 4...